Ann Arbor, Mich.From the Division of Plastic and Reconstructive Surgery, University of Michigan Hospital, and the Division of Plastic Surgery and Department of Neurosurgery, University of Michigan Medical School.
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Clefting of the palate is one of the most common deformities in the craniofacial skeleton, with more than 6800 children born with a cleft palate each year in the United States.1 Most of these children are referred to a surgeon for definitive repair; however, palatal fistulas and transverse growth restriction remain a significant problem for clinicians regardless of the center and type of repair.2,3 The main cause of these complications is a lack of tissue creating tension at the closure, as well as healing by secondary intention and subsequent growth restriction. To address these concerns, we describe a new technique of cleft palate repair using pedicled buccal fat pad flaps as an added tissue layer. Previous buccal fat pad uses include closure after tumor excision,4–6 dentoalveolar defects,7 oroantral fistulas,8–10 and palatal defects.11,12 We describe a new use of the buccal fat pad flap: cleft palate repair coupled with pedicled buccal fat pad flaps to cover areas of exposed bone of the hard palate as well as midline areas of high tension. We believe this technique may decrease scar contraction and subsequent transverse maxillary growth restriction induced by the lateral hard palatal tissue defect, as well as buttress areas where fistula formation is most common. Technically, minimal time, skill, and dissection are needed to harvest this robust flap, and we think cleft surgeons will find this useful for challenging cleft palate and palatal fistula repairs.PATIENTS AND METHODSFourteen patients had buccal fat pad flaps used for cleft palate and palatal fistula repairs performed by two surgeons at a single institution. Ten patients with complicated cleft palates underwent primary palate repair using the newly described technique between April and December of 2007 as described below.MarkingsDouble reversing Z-plasties for a Furlow palatoplasty in conjunction with two hard palate mucoperisoteal flaps were drawn out. The buccal fat pad flap harvest sites were marked in the superior buccal sulcus at the level of the upper second molar (Fig. 1).Surgical TechniqueIncisions were made along the aforementioned lines. The hard palatal mucoperiosteum was raised as two flaps pedicled by the palatine vessels. The nasal portion of the mucosa was dissected off of the maxilla. Next, double reversing nasal and oral Z-plasties were dissected and transposed in the soft palate. Finally, the midline two hard palatal mucoperiosteal flaps were closed creating a wide gap of bone around the patient’s hard palate (Fig. 2).To harvest the buccal fat pad flap, a curved iris scissor was placed in the superior buccal sulcus just lateral to the maxillary tuberosity and inserted directly through the mucosa resulting in buccal fat pad extrusion (see Video, Supplemental Digital Content 1, which exhibits the harvest, teasing out, and inset of the buccal fat pad flap, http://links.lww.com/A767; this video contains footage from two operations. In the first operation, the surgeon demonstrates the harvest and use of the buccal fat pad flap to fill in the lateral hard palatal exposed bone resulting from closure of the hard palatal mucoperiosteal flaps in the midline. The second half of the video shows footage of buccal fat pad flap harvest from the same site and demonstrates how far this flap can reach. In this second half, the buccal fat pad flap is used as an added layer to repair a palatal fistula.). The fat and fascia were teased out (Fig.